Coronary sinus collapsibility index and inferior vena cava collapsibility index can predict right atrial pressure in patients undergoing right heart catheterization.

BACKGROUND: The aim of the study is to investigate the relationship between the diameters and collapsibility indices of coronary sinus (CS) and inferior vena cava (IVC) and invasively measured right atrial pressure (RAP), and to determine whether these parameters have predictive value on RAP. METHODS: A total of 136 patients undergoing right heart catheterization due to pulmonary arterial hypertension were included in the study prospectively. CS diameters, IVC diameters, CS collapsibility index (CSCI), and IVC collapsibility index (IVCCI) were measured by echocardiography before catheterization. Pearson correlation analysis was used to compare the parameters. Receiver operating characteristics (ROC) curve analysis was used to determine the predictive value of the CS and IVC collapsibility indices in predicting RAP. RESULTS: Patients were divided into two groups as invasively measured RAP≥10 mm Hg (n:57) and RAP < 10 mm Hg (n:79). In the group with RAP≥10 mm Hg, IVC and CS diameters were higher than in the group with RAP < 10 mm Hg, while the IVCCI and CSCI were lower (p < 0.001). A negative correlation was observed between CSCI and IVCCI and RAP. Also, a positive correlation was observed between CSCI and IVCCI. Optimal cut-off value for IVCCI was 46.1 with a sensitivity of 75%, and specificity of 79.7%. Optimal cut-off value for CSCI was 39.2 with a sensitivity of 75.4%, and specificity of 88.6%. CONCLUSION: CS and IVC diameters and collapsibility indices measured by echocardiography were found to be associated with invasively measured RAP, and may be used together for estimating RAP.

Melatonin protects against streptozotocin-induced diabetic cardiomyopathy through the mammalian target of rapamycin (mTOR) signaling pathway.

BACKGROUND: Several studies demonstrated that the overexpression of mammalian target of rapamycin (mTOR) signaling protein is associated with cardiomyopathy. However, the effect of mTOR on the heart in hyperglycemic condition is still controversial. OBJECTIVES: We aimed to investigate the expression of mTOR and antioxidant enzyme activity in cardiac hypertrophy in rats with streptozotocin-induced diabetes mellitus (DM), and the effects of the melatonin on diabetic cardiomyopathy (DCM). MATERIAL AND METHODS: Forty male Wistar rats were used as the experimental animals. The rats were divided into 4 groups (10 animals in each): group 1 (control group), group 2 (ethanol vehicle group), group 3 (iatrogenically DM-induced group), and group 4 (group given melatonin after iatrogenical DM induction). Streptozotocin was injected intraperitoneally to group 3 and 4 to induce experimental type 1 DM. Melatonin was injected intraperitoneally at a dose of 50 mg/kg/day for 56 days to group 4. We investigated expression of mTOR levels in heart muscle fibers of all groups. Laboratory analysis and transthoracic echocardiography were performed. RESULTS: Melatonin increased the activity of superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx), which were reduced due to hyperglycemia. The mTOR expression levels were significantly higher in group 3 (DM group) compared with controls, whereas melatonin treatment significantly decreased the levels of mTOR expression in group 4 (melatonin + DM group). Diabetic rats developed myocardial hypertrophy with preserved cardiac function. CONCLUSIONS: Cardioprotective effect of melatonin may reduce damages caused by DM in the heart muscle fibers through the mTOR signaling pathway.

Aortic-flow propagation velocity is associated with proteinuria and left ventricular hypertrophy in newly diagnosed hypertensive patients.

OBJECTIVE: Subclinical target organ damage (TOD) is an important long-term complication of hypertension and is associated with cardiovascular events and death. Aortic-flow propagation velocity (APV) is one of the arterial stiffness parameters. The aim of this study was to investigate the predictive value of APV on left ventricular hypertrophy (LVH) and proteinuria. METHODS: A total of 149 newly diagnosed HT patients were included in the study. Urine samples and blood tests were obtained from each patient for diagnosis of proteinuria. All patients underwent echocardiographic examination. All patients' APV measurements, carotid intima-media thicknesses (CIMT), and ankle-brachial indexes (ABI) were measured and recorded. RESULTS: The LVH (+) group consisted of 47 patients, and the LVH (-) group consisted of 102 patients. The proteinuria (+) group consisted of 32 patients, and the proteinuria (-) group consisted of 117 patients. Average CIMT was significantly higher in both proteinuria (+) and LVH (+) groups compared with the (-) groups. ABI and APV were significantly lower in both proteinuria (+) and LVH (+) groups compared with the (-) groups. APV was negatively correlated with LVH, proteinuria, and CIMT and positively correlated with ABI. In the multivariate binary logistic regression analysis, APV was the significant independent predictor of proteinuria. Additionally, APV and ABI were found to be independent predictors of LVH or/and proteinuria. CONCLUSION: Hypertensive patients who had TOD had worse consequences of APV, CIMT, and ABI. APV had a powerful predictive value to identify the patients with higher risk of TOD among newly diagnosed hypertensive patients.

Melatonin protects against streptozotocin-induced diabetic cardiomyopathy by the phosphorylation of vascular endothelial growth factor-A (VEGF-A).

The aim of the present study is to investigate if the melatonin has any protective effect on diabetic cardiomyopathy and antioxidant enzymes via phosphorylation of vascular endothelial growth factor-A (VEGF-A). A total of 40 male Wistar rats were enrolled in the study. Rats were divided into four groups: group 1 (control, n=10), group 2 (DM, n=10), group 3 (melatonin, n=10), and group 4 (melatonin+DM, n=10). Melatonin was injected intraperitoneally at a dose of 50 mg/kg/day for 56 days to group 3 and group 4. We investigated expression and phosphorylation of the VEGF-A in coronary vessels of all groups. Staining intensities, biochemical, immunohistochemistry analysis, and transthoracic echocardiography were performed. In comparison to the group 1, DM induced a decrease in p-VEGF-A in coronary vessels of group 2. The lower constitutive phosphorylation of VEGF-A in the group 2 was also increased in coronary vessels after melatonin treatment (p<0.05). Diabetic rats developed myocardial hypertrophy with preserved cardiac function (p<0.05). Cardio-protective effect of melatonin may reduce the damages of diabetes mellitus on the heart muscle fibers and coronary vessels via the phosphorylation of VEGF-A. Melatonin-dependent phosphorylation of VEGF-A in coronary angiogenesis may be associated with the physiological as well as with the pathological cardiac hypertrophy.

Compliance With Dyslipidemia Guidelines in Daily Practice: How Effective Is Cardiovascular Risk Prevention?

PURPOSE: Cardiovascular disease (CVD) due to atherosclerosis is the leading cause of early mortality and morbidity. The current European guidelines on CVD prevention in clinical practice recommend the use of the Systematic Coronary Risk Estimation (SCORE) system. The current American Heart Association guidelines recommend the use of the new pooled cohort risk assessment equations to estimate the 10-year atherosclerotic CVD risk. The purpose of this article was to investigate the compliance of dyslipidemia guidelines in daily practice in patients with dyslipidemia or who have risk factors for CVD. METHODS: The study group consisted of 500 outpatients who had dyslipidemia or risk factors for CVD. The risk level was computed according to the European and American Heart Association guidelines. Therapeutic LDL-C targets were identified based on the calculated risk level. Therapeutic target levels were compared based on the dosage of statins used and achievement of the LDL-C goal in daily practice according to the risk levels. FINDINGS: According to the European dyslipidemia guidelines, 231 patients were in the very-high/high-risk group, and 106 patients (45.9%) achieved the LDL-C target (<100 mg/dL); 210 patients were in the moderate-risk group, and 156 (74.3%) patients achieved the LDL-C target (<115 mg/dL); and 59 patients were in the low-risk group, and 55 (93.2%) patients achieved the LDL-C target (<155 mg/dL). Univariate and multivariate logistic regression analyses revealed that the LDL-C level and presence of coronary artery disease were significantly reverse associated with achievement of the LDL-C goal (both, P < 0.001). IMPLICATIONS: Our results showed that the majority of patients were in the very-high/high-risk group in daily practice. Although the European dyslipidemia guidelines are more likely to be used in daily practice, achievement of the guidelines-recommended treatment goals was low.

ST segment elevation myocardial infarction (STEMI) patients are more likely to achieve lipid-lowering treatment goals: A retrospective analysis of patients presenting with first acute coronary syndromes.

Statin nonadherence or discontinuation is associated with increased cardiovascular events. Many factors related to the physicians or the patients are influential in this. We aimed to compare the compliance with statin therapy between the patients who first presented with ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UA) based on the target achievement according to the current dyslipidemia guidelines.We retrospectively acquired all the information about demographic characteristics, in-hospital revascularization procedures, prescribed treatments, and index and up to 6-month follow-up laboratory results of the first acute coronary syndrome patients. Acute coronary syndrome patients were divided into 3 groups as STEMI, NSTEMI, and UA.The STEMI group consisted of 260 patients, NSTEMI group consisted of 560 patients, and UA group consisted of 206 patients. Seventy-six percent of patients underwent percutaneous coronary interventions, 18.3% were managed medically, and 5.7% were referred for coronary artery bypass grafting. There was a significant decrease in low-density lipoprotein-cholesterol (LDL-C) values with the statin treatment at the follow-up in all 3 groups (for all P < .001). In the STEMI group, the percentage of those achieving the target LDL-C level was significantly higher than those who did not achieve the target according to both The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology dyslipidemia guidelines. The LDL-C target achievement rates were also higher in the STEMI group than in the NSTEMI and UA groups.Our study concluded that statin treatment goals were more attained in STEMI patients than NSTEMI and UA. All physicians should encourage lifelong intensive statin treatment in UA and NSTEMI patients such as STEMI patients.

Rupture of Sinus of Valsalva Aneurysm into Left Atrium in a Patient who is a Candidate for Hepatic Transplantation.

Sinus of valsalva aneurysm (SVA) is a rare cardiac disease. The most common complication of SVA is rupture into the right atrium or right ventricle. Rupture into the left chambers is very rare. Patients with ruptured SVA are likely to die of heart failure or endocarditis. We present a 29-year-old man who was hospitalized for hepatic transplantation with rupture of SVA. Transthoracic echocardiography and transesophageal echocardiography showed rupture of a noncoronary SVA into the left atrium. Mitral valve infective endocarditis developed and surgery was planned for the patient, but the patient died due to multiple organ dysfunction syndrome.

Evaluation of atrial electromechanical functions in dipper and nondipper hypertension patients using left atrial strain P-wave dispersion and P terminal force.

OBJECTIVE: Nondippers are known to carry a high risk of cardiovascular morbidity and mortality. The aim of this study was to investigate the effects of dipper and nondipper status of hypertension on left atrial (LA) systolic and diastolic functions using two-dimensional speckle tracking echocardiography (2D-STE), P-wave dispersion (PWD), and P terminal force (PTF) in hypertensive patients. METHODS: A total of 72 patients and 39 healthy individuals were included in the study. The patients were classified as nondippers if their daytime ambulatory systolic and diastolic blood pressure did not decrease by at least 10% during the night. Atrial electromechanical delay times, LA strain values were obtained by 2D-STE with automated software and compared between the groups. PWD and PTF data were calculated on the electrocardiography. RESULTS: Inter-atrial (dippers: 25.5 ± 3.9, nondippers: 32.2 ± 7.4, P < .001), left-atrial (dippers: 14.9 ± 3.7, nondippers: 18.2 ± 6.0, P = .016), and right atrial (dippers: 10.5 ± 2.1, nondippers: 14.2 ± 5.2, P < .001) electromechanical delay times were significantly longer in nondippers. LA strain S (dippers: 34.2 [29.7-38.7], nondippers: 27.7 [22.7-32.2], P < .001), LA strain E (dippers: 18.2 [16.6-20.1], nondippers: 14.4 [11.6-16.8], P < .001), and LA strain A (dippers: 15.8 [13.5-17.9], nondippers: 12.7 [9.9-14.5], P < .001) were significantly lower in nondippers. Nondippers also had an increased values of maximum P-wave duration (dippers: 0.117 [0.10-0.12], nondippers: 0.126 [0.12-0.14], P < .001), PWD (dippers: 0.062 [0.06-0.07], nondippers: 0.069 [0.06-0.08], P = .004), and PTF (dippers: 0.055 ± 0.02, nondippers: 0.066 ± 0.02, P = .02). CONCLUSION: Nondipping pattern in hypertensive patients had a worse cardiac remodeling, and impaired mechanical LA function compared with dipping pattern. The PWD and PTF findings support these changes.

Development of massive pulmonary embolism during echocardiographic imaging: A case report.

RATIONALE: Pulmonary embolism (PE) is a common diagnostic consideration for patients who present to the emergency department (ED) with chest pain, dyspnea, or both. In addition, PE has a very high mortality in patients who are hemodynamically unstable. An electrocardiography, bedside transthoracic echocardiogram, and computed tomography pulmonary angiogram are usually performed to confirm the diagnosis. PATIENT CONCERNS: A 53-year-old man was admitted to the cardiology clinic with complaints of dyspnea, chest pain, and general weakness after walking. He had a history of hypertension and smoking. DIAGNOSIS: During synchronous recording of echocardiographic images, a large mobile thrombus detached from the right atrium, and first embolized to the right ventricle and then to the main pulmonary artery from the right heart chambers. Soon after, shortness of breath developed which clinically worsened the patient. Transthoracic echocardiogram which demonstrated the thrombus in the pulmonary artery or right heart chambers was suspected of causing acute massive PE. INTERVENTIONS: The patient was transferred to Critical Care Unit for monitoring; 100 mg of alteplase was initiated immediately and alleviated the hemodynamic instability within 2 hours of intravenous administration. OUTCOMES: To the best of our knowledge, this is the first synchronous echocardiographic recording showing the embolization of a thrombus from the right atrium, first to the right ventricle and then to the main pulmonary artery. LESSONS: Transthoracic echocardiography provides a safe, rapid, and noninvasive diagnostic tool for evaluation of suspected massive PE. Thrombolytic therapy is useful for treating acute massive PE that leads to hemodynamic instability.

[Congenitally corrected transposition of the great arteries in patient with atrial septal defect and acute inferior segment myocardial infarction]. / Ileri yasta akut inferiyor miyokart enfarktüsü ile basvuran ve atriyal septal defekt anomalisinin eslik ettigi dogumsal düzeltilmis büyük arter transpozisyonu.

Congenitally corrected transposition of the great arteries is a rare abnormality accounting for approximately 1% of clinically apparent congenital heart disease. Age at time of diagnosis and survival rate vary and depend on associated anomalies, including pulmonary stenosis, ventricular septal defect, atrial septal defect, atrioventricular block, and atrioventricular valve regurgitation. Reported cases of corrected transposition of the great arteries with single coronary ostium anomaly and atrial septal defect are very rare. Described in the present report is the case of a 55-year-old male who presented with acute inferior ST-segment elevation myocardial infarction and coincidental single coronary ostium arising from the right sinus of Valsalva, as observed on coronary angiography. Successful balloon angioplasty and stenting of the circumflex artery were performed. Echocardiography demonstrated the corrected transposition of the great arteries with negative contrast enhancement between the atrial chambers. The patient was discharged with medical therapy on the eighth postoperative day. To our knowledge, the present is the first report to describe corrected transposition of the great arteries, atrial septal defect, single coronary ostium, and acute myocardial infarction as comorbidities.

Association of aortic flow propagation velocity with ankle-brachial blood pressure index in patients with hypertension: an observational study.

OBJECTIVE: Endothelial dysfunction is considered the first stage in the development of atherosclerosis and assessed by flow-mediated dilatation (FMD) and aortic flow velocity propagation (AVP). Ankle-brachial index (ABI) is used to assess peripheral arterial disease and is associated with FMD but the relationship between ABI and AVP is unknown. In this study, we aimed to search the association between AVP, and ABI in patients with newly diagnosed hypertension. METHODS: Sixty-eight patients with newly diagnosed hypertension and 34 healthy subjects were enrolled in the cross-sectional observational study. The maximum ankle arterial pressures were divided by the maximum of the brachial arterial pressures to calculate the ABI. AVP was calculated from dividing the distance between points corresponding to the beginning and end of the propagation slope, to the duration between corresponding time points proximally descending aorta. Statistical analysis was performed using Student t-test, Chi-square test, Pearson correlation and linear regression analyses. RESULTS: Age and gender of both groups were similar. Compared to control group E deceleration time of early diastolic flow velocity (184.0±32.2 vs. 217.1±38.6, p<0.001), isovolumic relaxation time (95.5±19.4 vs. 105.7±18.1, p<0.001) and body mass index (25.6±5.1 vs. 27.5±3.8, p=0.044) values were significantly higher, while ABI (1.08±0.07 vs. 1.14±0.07, p=0.001) and AVP (54.97±9.3 vs. 69.17±10.8 cm/sec, p=0.001) values were significantly lower in hypertensive patients. There was a significant correlation between AVP and ABI (r=0.279, p=0.005). Both ABI and AVP were independent predictors of hypertension (OR - 0.353, 95%CI 0.151-0.826, p=0.02 and OR - 0.133, 95%CI 0.0502-0.35, p=0.001, respectively). CONCLUSION: Our data indicate that in patients with isolated hypertension AVP and ABI decrease. We also conclude that AVP is directly associated with ABI.

Paraoxonase and arylesterase activities in stent restenosis in bare metal stent.

BACKGROUND AND OBJECTIVE: The serum paraoxonase and arylesterase activities are related to coronary artery diseases. However, there are a few data about the association of paraoxonase and arylesterase activities with in-stent restenosis (ISR). The aim of this study was to evaluate the relationship between paraoxonase and arylesterase activities and ISR in patients with bare metal stent (BMS). MATERIALS AND METHODS: Thirty-one patients with normal coronary artery (group 1) and 60 with BMS were enrolled in this observational study. According to the ISR, the patients were classified as group 2, without the ISR (n=29) and group 3, with the ISR (n=31). Serum paraoxonase and arylesterase activities were measured spectrophotometrically. RESULTS: The paraoxonase and arylesterase activities were lower in patients with BMS than in the individuals with normal coronary artery (P < 0.001 and P = 0.001, respectively). The enzyme activities were also higher in patients without ISR than with ISR (both of P < 0.001). In bivariate correlation analyses in patients with BMS, ISR shows significant positive correlations with the presence of hypertension and hyperlipidemia, type C lesion, and stent length, but shows negative correlations with type A lesion stent diameter, high-density lipoprotein cholesterol, and paraoxonase and arylesterase activities. In regression analysis, ISR is independently associated with paraoxonase and arylesterase activities (ß = -0.216, P = 0.038 and ß = -0.452, P < 0.001, respectively), type A lesion (ß = -0.251, P = 0.013), and stent diameter (ß = -0.192, P = 0.024) in patients with BMS. CONCLUSION: Our study shows that decreased paraoxonase and arylesterase activities play a significant role in ethiopathogenesis ISR in patients with BMS.

The effects of perindopril on QT duration and dispersion in patients with coronary slow flow.

Coronary slow flow (CSF) is characterized by delayed opacification of coronary arteries in the absence epicardial occlusive disease. QT duration and dispersion have been reported to be longer in patients with CSF. ACE inhibitors may improve CSF through positive effects on endothelial function. The study included 32 patients having CSF and 25 subjects having normal coronary arteries in coronary angiography. The patients were evaluated with 12-leads electrocardiography and echocardiography before and 3 months after treatment with perindopril. Compared to the control group, maximum corrected QT duration (QTcmax) (432.0 ± 28.9 vs. 407.0 ± 39.1 ms, p = 0.008) and QT dispersion (QTcD) (64.0 ± 16.5 vs. 37.3 ± 12.1 ms, p < 0.001), mitral inflow deceleration time (DT) (251.3 ± 49.4 vs. 218.8 ± 44.5 ms, p = 0.013), and isovolumetric relaxation time (IVRT) (115.8 ± 18.4 vs. 107.2 ± 22.9 ms, p < 0.001) were significantly longer and E/A ratio 0.85 ± 0.2 vs. 1.1 ± 0.3, p = 0.004) was lower in patients with CSF. QTcmax (to 407.0 ± 28.0 ms, p = 0.001), QTcD (to 44.5 ± 11.4 ms, p < 0.001), DT (to 221.6 ± 37.7 ms, p < 0.001) and IVRT (to 103.8 ± 16.1 ms, p < 0.001) were significantly decreased and E/A ratio (to 0.98 ± 0.3, p < 0.001) was significantly increased after treatment with perindopril. Coronary slow may be associated with prolonged QT interval and increased QT dispersion and impaired diastolic filling. Perindopril may be helpful in restoration of these findings.

Effects of statin use on total oxidant and antoxidant capacity and ceruloplasmin activity.

PURPOSE: Oxidative damage plays an important role in atherosclerosis development. Statin drugs have anti-oxidant properties, but the clinical value of their antioxidant properties remains unclear. In this study, our aims were: (1) to assess the anti-oxidant effects of statins in patients with coronary artery disease (CAD) using a newly developed valid measure of total oxidant and anti-oxidant capacity; and (2) to identify whether statins influence ceruloplamin levels. METHODS: Within a cross-sectional study, 67 dyslipidemic CAD patients on atorvastatin for at least three months were compared with 69 age- and gender-matched CAD patients not using atorvastatin. All patients were either newly-diagnosed with or already had established CAD. Patients and controls were selected from among patients who had undergone coronary angiography for a variety of reasons. Immediately prior to angiography, plasma total oxidant and antioxidant capacity and ceruloplasmin (Cp) levels were measured by means of a relatively new and highly-reliable method. RESULTS: Total oxidant capacity levels were significantly lower and total antioxidant capacity significantly higher in those on atorvastatin; serum seruloplasmin levels also were significanly increased in the atorvastatin groups (all p < 0.05). On multivariate analysis, atorvastatin use was a significant determinant of Cp increase, independent of any antioxidant effect. CONCLUSIONS: This study clearly demonstrates increased anti-oxidant capacity and decreased oxidative stress with statin use. Atorvastatin use may also increase Cp levels although this effect appears to be independent of its anti-oxidant effects.

Acute renal failure with the combined use of rosuvastatin and fenofibrate.

Among the lipid-lowering drugs, the statins and fibrates are the most commonly used agents. Either class of drug is considered relatively safe. Though a variety of albeit uncommon adverse side effects have been observed with both classes, most of these therapeutic complications can be managed without discontinuation of the offending drug. Sometimes, especially in patients with extremely high cholesterol and/or triglyceride levels, a combination regimen is deemed necessary. However, the combined use of lipid-lowering drugs increases the incidence and severity of adverse events. In this article, we report an unusual case of acute renal failure (ARF) in a patient who had been prescribed both a statin (rosuvastatin) and a fibrate (fenofibrate).

The relation between the color M-mode propagation velocity of the descending aorta and coronary and carotid atherosclerosis and flow-mediated dilatation.

BACKGROUND: To improve clinical outcomes, noninvasive imaging modalities have been proposed to measure and monitor atherosclerosis. Common carotid intima-media thickness (CIMT) and brachial artery flow-mediated dilatation (FMD) have correlated with coronary atherosclerosis. Recently, the color M-mode-derived propagation velocity of descending thoracic aorta (AVP) was shown to be associated with coronary artery disease (CAD). METHODS: CIMT, FMD, and AVP were measured in 92 patients with CAD and 70 patients having normal coronary arteries (NCA) detected by coronary angiography. Patients with acute myocardial infarction, renal failure or hepatic failure, aneurysm of aorta, severe valvular heart disease, left ventricular ejection fraction <40%, atrial fibrillation, frequent premature beats, left bundle branch block, and inadequate echocardiographic image quality were excluded. RESULTS: Compared to patients with normal coronary arteries, patients having CAD had significantly lower AVP (29.9 +/- 8.1 vs. 47.5 +/- 16.8 cm/sec, P < 0.001) and FMD (5.3 +/- 1.9 vs. 11.4 +/- 5.8%, P < 0.001) and higher CIMT (0.94 +/- 0.05 vs. 0.83 +/- 0.14 mm, P < 0.001) measurements. There were significant correlations between AVP and CIMT (r =-0.691, P < 0.001), AVP and FMD (r = 0.514, P < 0.001) and FMD and CIMT (r =-0.530, P < 0.001). CONCLUSIONS: The transthoracic echocardiographic determination of the color M-mode propagation velocity of the descending aorta is a simple practical method and correlates well with the presence of carotid and coronary atherosclerosis and brachial endothelial function.